OCD and Medication
Dr Jonathan Haverkampf
OCD should be treated with a combination of psychotherapy and medication, if the symptoms are too severe to be treated with psychotherapy alone. If the rituals and/or intrusive thoughts and thoughts patterns interfere with life in such a way that its quality is noticeably reduced and/or that the patient cannot function anymore at the workplace or in relationships, then there is a strong case for medication.
Effective medication is primarily from the class of selective serotonin reuptake inhibitors (SSRIs), which increase the intrasynaptic levels of the neurotransmitter serotonin and thereby change the serotonin receptor density and the intracellular information transmission, which is probably primarily responsible for the effect of SSRIs on depression, anxiety, OCD and several other conditions, depending on the receptor subtype and the localization in the brain. It is also responsible for an increase in appetite in many SSRIs.
SSRIs seem to work because they reduce the anxiety that maintains the OCD and resurfaces if one tries to suppress the symptoms of the OCD. SSRIs are usually tried first because they act predominantly on the serotonin system and have relatively safe side-effect profiles, but this does not mean that the effect does not proceed through other neurotransmitter systems as well, which can also play a role.
Generally, all SSRIs can have an effect of OCD, and it is a matter of taste and empirical experience which one prefers. While a couple of years ago there was a preference for paroxetine, this might now be shifting to escitalopram, which is by many patients reported to be better tolerated.
In very severe cases with intrusive thoughts one can also add a neuroleptic, whereby possible cross interactions should be kept in mind. One should avoid combinations that can increase the risk of the otherwise very rare serotonin syndrome, which can be life-threatening and requires intensive care. Also, one needs to be careful with combinations that prolong the QT time. Olanzapine (Zyprexa®) appears to be the least problematic on the last point, but it also can prolong the QT time.
SSRIs that have been recommended repeatedly are the following:
- Citalopram (Cipramil®)
- Escitalopram (Cipralex®)
- Fluoxetine (Prozac®)
- Fluvaxamine (Luvox® and Faverin®)
- Paroxetine (Paxil® and Seroxat®)
- Sertraline (Lustral® and Zoloft®)
The NICE guidelines for the treatment of OCD now only recommend two of these medications for use in treating children with OCD. These are Sertraline for children aged 6 years and older and Fluvoxamine for children aged 8 years and older. However, there seems to be no theoretical reasons, why, for example, the newer and usually very well tolerated escitalopram should not also be useful in this regard.
Typically, the process of determining the most suited medication for an individual is achieved on a trial-and-error basis. However, to allow its maximum effects to be adequately observed, each medication should be taken for a specified time, usually for at least 12-16 weeks, before seeking out an alternative.
If these medications fail to work, a non-selective SRI may be prescribed. However, because it affects neurotransmitters in the brain, other than just serotonin, there are more side effects and therefore it is usually not a first-choice medication for treating OCD.
Clomipramine (Anafranil®) is a non-SSRI tricyclic antidepressant that has been used in the past and may be a secondary choice to the SSRIs. The NICE guidelines state Clomipramine should be considered in the treatment of adults with OCD or BDD after an adequate trial of at least one SSRI has been ineffective or poorly tolerated, or if the patient prefers Clomipramine or has had success in using the medication before.
Although SSRIs can be stopped quite easily, it is sensible to reduce them gradually. NICE recommend that if the medication has helped, one should continue taking the medication for at least 12 months to ensure your symptoms continue to improve. This makes it also more likely that there will be an often empirically observed protective after-effect after stopping them.
© Dr Christian Jonathan Haverkampf. All rights reserved.
Psychotherapy & Counselling, Communication, Medicine (Psychiatry); Dublin, Ireland
This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition.
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